Post oral
surgery bleeding for adult
patients receiving
antithrombotic therapy
Saudi Arabia
Background
 King Fahd Medical City is a large tertiary care hospital with 1095 beds.
 The American College of Chest Physicians guidelines recommend that
routine dental procedures including extractions, scaling and restorative
treatment could be done without the interruption of Warfarin, a Vitamin K
Antagonist (VKA) if the International Normalized Ratio (INR) is within the
therapeutic range and local hemostatic agents are used.¹
 The American Heart Association guidelines recommend that anticoagulant
such as Clopidogrel do not need to be stopped for dental procedures.²
 The recommendation in the Journal of Canadian Dental Association is that
Enoxaparin should have the morning dose held.³
 The American Dental Association stated ‘ it is generally agreed that
anticoagulant [including antiplatelet] drug regimens should not be altered
prior to dental treatment.’4
Rationale
 Little existing data in Saudi Arabia for antithrombotic
(anticoagulant and anti-platelet) therapeutic doses and
their effects on post-oral surgery bleeding.
 There is an urgent need to standardize the practice for
treating such patients because evidence from a survey
we conducted showed that a high number of local
dentists are unwilling or unsure how to treat patients on
antithrombotic medications. This will lessen the delays
that the patient faces in receiving treatment.
5
Survey about perceptions of dentists in
Saudi Arabia about treating patients on
anti-thrombotic therapy
Dentist familiarity with antithrombotic
medications
No. of dentists
What % of dentists would not treat a patient or
are unsure how to treat on antithrombotic
medications
Objectives
 Is to assess the post oral surgery bleeding incidence
in adult patients on antithrombotic once
implementing the following protocol:
 Warfarin: Medication to be continued. Recent (within 24 hours)
INR values to be within therapeutic range.
 Clopidogrel: Medication to be continued.
 Enoxaparin: Morning dose to be held.
 Local hemostatic agents available to be used as deemed necessary
i.e. sutures, collagen, tranexamic acid.
 To reduce the interruption of antithrombotic
medications
Study Design
 A prospective cohort single-centre two year study of
all patients on antithrombotic medications
undergoing oral surgery within King Fahd Medical
City (KFMC) Department of Dentistry.
 All patients within the inclusion criteria were
monitored
Inclusion and exclusion criteria
 Inclusion
 Patients for oral surgery in KFMC Department of
Dentistry and under the care of a KFMC physician
 Patients treated under local anesthesia
 Patients 18 years old or over
 Taking the afore-mentioned antithrombotic medications
according to the protocol described
 Exclusion
 Patients treated under general anesthesia
 Any patients stopped antithrombotic medication without
physician approval
 Sub-therapeutic or supra-therapeutic INR values for
patients taking Warfarin
 Patients with advanced liver disease
Variables
Methodology
 Protocol:
 Local hemostatic agents available to be used as deemed necessary i.e.
sutures, collagen, tranexamic acid.
 Warfarin: Medication to be continued. Recent (within 24 hours) INR
values to be within therapeutic range.
 Clopidogrel: Medication to be continued.
 Enoxaparin: Morning dose to be held.
 All patients who were underwent oral surgery procedures were
monitored for post-operative bleeding.
 Bleeding was defined as serious post-operative bleeding after the
patient has been discharged from the clinic > 12 hours, or bleeding
necessitating return to a medical facility and further measures (e.g.
use of hemostatic agents).
Results
 Out of 353 visits there were only two incidences of bleeding
necessitating return to a medical facility (0.56%)
 The average INR value for the patients receiving Warfarin was
1.9
 Treatment done:
 826 extractions
 14 alveolectomies
 3 bone grafts
 2 implants
 1 biopsy
Antithrombotic Medications
353 cases
147
Clopidogrel
122
Warfarin
86
Enoxaparin
Antithrombotic Medications studied
Anticoagulant
Vitamin K Antagonist
(VKA)
Warfarin
Anticoagulant
Low Molecular Weight
Heparin (LMWH)
Enoxaparin
Antiplatelet
P2Y12 receptor inhibitors
Clopidogrel
15
15
16
21
21
21
21
36
27
32
26
32
28
31
33
43
31
37
36
35
30
28
27
22
34
16
21
19
19
16
18
19
Number of
teeth
extracted per
notation
Patient Demographics - Gender
Patient Demographics – Age distribution
(Average age = 50.7 years, range 18 - 88 years)
Patient Demographics – Medical
Conditions
Conclusion
Our finding supported the following for patients
undergoing oral surgery procedures provided local
hemostatic agents are available to use as necessary:
• Warfarin: can safely be continued during oral
surgery procedures as long as the INR is within
the therapeutic range
•Clopidogrel: can safely be continued during oral
surgery procedures
•Enoxaparin: the morning dose should be held
Obstacles we faced
 Some loss of patients to follow up
Recommendations for further
study
 The recent introduction of Novel Oral Anticoagulants
(NOACs) such as Dabigatran and Rivaroxaban mean that they
should be studied for incidence of bleeding.
 To include dental hygiene patients.
References
¹ Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic
therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest
Physicians evidence-based clinical practice guidelines. Chest 2012;141(2) (Suppl):e326S-50S.
Available: http://journal.publications.chestnet.org/data/Journals/CHEST/23443/112298.pdf
Accessed: February 19, 2013
² Grines CL, Bonow RO, Casey DE et al. Prevention of premature discontinuation of antiplatelet
therapy in patients with coronary artery stents: a science advisory from the American Heart
Association, American College of Cardiology, Society for Cardiovascular Angiography and
Interventions, American College of Surgeons, and American Dental Association, with
representation from the American College of Physicians. Circulation 2007;115:813-8. Available:
http://circ.ahajournals.org/content/115/6/813.full.pdf+html
³ Davies C, Robertson C, and Shivakumar S. Implications of Dabigatran, a Direct Thrombin
Inhibitor, for Oral Surgery Practice. J Can Dent Assoc 2013;79:d74
American Dental Association, Anticoagulant, antiplatelet medications and dental procedures
http://www.ada.org/2959.aspx?currentTab=1 Accessed: February 27, 2013
5 Al-Mubarak, S., Al-Ali, N., Abou Rass, M. et al Evaluation of dental extractions, suturing and INR
on postoperative bleeding of patients maintained on oral anticoagulant therapy Br. Dent. J. 2007;
203(7);e15
6 Nooh, N., Dental Management of patients receiving anticoagulant therapy Saudi Dental Journal,
Volume 21, No.1, January – April 2009
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